Indications of ICD in 2010 Dr Mervat Aboulmaaty Professor of Cardiology Ain Shams University DAF 1 st EP course 2010

SCD Burden

SCD Risk

ICD Implantable Cardiovertor Defibrillator

First human implants Thoracotomy, multiple incisions Primary implanter= cardiac surgeon General anesthesia Long hospital stays Complications from major surgery Perioperative mortality up to 9% Nonprogrammable therapy High-energy shock only Device longevity  1.5 years Fewer than 1,000 implants/year 1980: Large Devices, Limited Battery Life, Abdominal Implant, Epicardial Leads

First-line therapy for VT/VF patients Treatment of atrial arrhythmias Cardiac resynchronization therapy for HF Transvenous, single incision Local anesthesia; conscious sedation Short hospital stays and few complications Perioperative mortality < 1% Programmable therapy options Single- or dual-chamber therapy Battery longevity up to 9 years* More than 100,000 implants/year Today: Small Devices, Long Battery Life, Pectoral Implant, Endocardial Leads *Battery longevity information in slide notes.

Atrium & Ventricle Bradycardia sensing & Pacing Atrium  AT/AF tachyarrhythmia detection  Antitachycardia pacing  Cardioversion Ventricle  VT/ VF detection  Antitachycardia pacing  Cardioversion  Defibrillation Therapies Provided by Today’s Dual-Chamber ICDs

CRT-D Multisite ICD

Indications for ICDs Primary – Prevent a SCD event before it occurs Define patients at risk Secondary – Prevent SCD event after an initial event survival Exclude transient or reversible causes for VF

MADIT 1996 (196 patients) MADIT 1996 (196 patients) * M ild HF”:NYHA Class I and II ; High-risk”:EF ≤30%; QRS ≥130ms MADIT II 2002 (1232 patients) MADIT II 2002 (1232 patients) MADIT-CRT 2005 (1820 patients) MADIT-CRT 2005 (1820 patients) Clinical Question: Can prophylactic ICD therapy improve survival in high risk HF patients when compared to medical therapy alone? Endpoint: All-cause mortality. Key Finding: Use of ICDs resulted in a 54% reduction in the mortality rate in the ICD group as compared to the conventional medical therapy group (p value: 0.009) Clinical Question: Can heart attack survivors with impaired heart function (EF≤30%), and no other risk stratification, benefit from ICD therapy versus conventional therapy alone? Endpoint: All-cause mortality. Key Finding: Use of ICDs resulted in a 31% reduction in the risk of death in heart attack survivors (p value: 0.016). As a result, patients no longer have to undergo invasive electrophysiological testing to receive the ICD therapy Clinical Question: Does early intervention with CRT-D slow the progression of HF in high-risk patients* with mild HF* when compared to ICD-only therapy? Endpoint: All-cause mortality OR first HF event. Key finding: CRT-D therapy is associated with a significant 34% reduction in death or first HF event when compared to ICD therapy alone (p value: 0.001)

1 Moss AJ. N Engl J Med. 1996;335: Buxton AE. N Engl J Med. 1999;341: Moss AJ. N Engl J Med. 2002;346: Moss AJ. Presented before ACC 51st Annual Scientific Sessions, Late Breaking Clinical Trials, March 19, The AVID Investigators. N Engl J Med. 1997;337: Kuck K. Circ. 2000;102: Connolly S. Circ. 2000:101: ICD mortality reductions in primary prevention trials are equal to or greater than those in secondary prevention trials. 13, Reductions in Mortality with ICD Therapy 54% 75% 55% 76% 31% 61% 27 months39 months20 months 31% 56% 28% 59% 20% 33% % Mortality Reduction w/ ICD Rx 3 Years

Class I Documented survivors of SCD due to VF 40days post MI + LVEF≤ 35 + NYHA II/III 40 days post MI + LVEF≤ 30 + NYHA I Non ischemic cardiomyopathy + LVEF≤ 35 + NYHA II/III Non sustained VT post MI + sustained VT/VF by EPS+ LVEF ≤ 40 Structural heart disease + sustained VT Syncope + unstable VT/VF by EPS

Class IIA LQTS + syncope/VT (on β blockers) Unexplained syncope + DCM + significant LV dysfunction Sustained VT + normal LV CPVT + syncope/VT (on β blockers) High risk ARVD High risk HCM Brugada syndrome + syncope/VT

Indications for ICD in HF patients

Guidelines of ICD in a Pocket

Indications for ICD implantation Class III ICD is NOT indicated IN Syncope of undetermined cause no VT induced NO structural HD Incessant VT VF VT/VF resulting from arrhythmias amenable for ablation as WPW Fasicular VT VT due to reversible disorder Significant psychological disorder Terminal illness life expectancy <6months

55 yr old, first hour of Acute MI

 ICDs are reliable devices that have the potential to add quality years of life for appropriate candidates.  There are scientifically-derived guidelines for their prescription that are limited by the scope of the clinical trials and observational data.  Cardiologists should recommend ICD devices to their individual patients based on the current guidelines. Conclusions

ICD Programming Zone Rate (bpm) Cycle Length (ms) No. of Beats to DetectTherapies VF> 250<24018 of 2430 J × 6 FVT Burst (1), 30 J × 6 VT< Burst (2), ramp (1), 20 J, 30 J × 3

How ICD works?

I C D I N T E R R O G A T I O N

VT Burst 1 Sinus I C D I N T E R R O G A T I O N

Burst Acc. VT VT I C D I N T E R R O G A T I O N

DC Sinus Acc.VT Cont.

Thank you